A 60-year-old woman presented with an irregular lesion in the skin over the midline of her chest of 3 months' duration (Figure 1). There was recent onset of pain. The patient had undergone coronary artery bypass surgery 8 years earlier. On examination, we found an irregular-shaped nodular lesion, with some areas of ulceration measuring 10 cm vertically and 5 cm horizontally. There was restricted mobility of the lesion over the sternum. The single axillary node was palpable in both axillae and measured 3 cm× 3 cm on the right side and 2.5 cm × 2.5 cm on the left side. Supraclavicular nodes were not palpable, and there were no clinical or radiologic signs of metastasis elsewhere. A computed tomographic scan of the chest with contrast revealed the lesion in the midline extending to both breasts but more evident on the right side (Figure 1). The sternum was not involved with the disease; however, a biopsy revealed moderately differentiated carcinoma (Figure 2A). Immunohistochemistry was performed to confirm the diagnosis of breast cancer. Immunohistochemistry was positive for CK7, CK20 (Figure 2B and C), and gross cystic disease fluid protein positive (Figure 2D).

Figure 1. A lesion in the midline over the sternum with small areas of ulceration. The inset of a computed tomographic scan of the thorax shows the lesion in the midline with extension into both breasts (more on the right). Note that the sternum is not infiltrated.

Figures

Figure 1. A lesion in the midline over the sternum with small areas of ulceration. The inset of a computed tomographic scan of the thorax shows the lesion in the midline with extension into both breasts (more on the right). Note that the sternum is not infiltrated.

Tables

References

Correspondence

The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with
the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.

Indicate what change(s) you will implement in your practice, if any, based on this CME course.

Your quiz results:

The filled radio buttons indicate your responses. The preferred responses are highlighted

For CME Course:
A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes

Indicate what changes(s) you will implement in your practice, if any, based on this
CME course.

Instructions

Thank you for submitting a comment on this article. It will be reviewed by JAMA Surgery editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.

Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.

* = Required Field

Response Author(s)* (if multiple authors, separate
names by comma)

Example: John Doe

Affiliation & Institution*

Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.

This feature is provided as a courtesy. By using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to the AMA's Terms of Use. The information provided in order to email this article will not be shared, sold, traded, exchanged, or rented. Please refer to The JAMA Network's Privacy Policy for additional information.

Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.